Heidi Hjelmeland

Why We Need Qualitative Research in Suicidology.

Using the differentiation between explanations and understanding from philosophy of science as the point of departure, a critical look at the current mainstream suicidological research was launched. An almost exclusive use of quantitative methodology focusing on explanations is demonstrated. This bias in scope and methodology has to a large extent taken the suicidological field into a dead-end of repetitious research. It is argued that an increased focus on understanding and thus extended use of qualitative methodology is essential in bringing the suicidological field forward.

Why people engage in parasuicide: a-cross-cultural study of Intentions.

Information obtained at interview from 1,646 parasuicide patients in 14 regions in 13 European countries participating in the WHO/EURO Multicentre Study on Suicidal Behaviour was used to study self-reported intentions involved in parasuicide. Comparisons were made across cultures, genders, and age groups. Although some statistically significant differences were found, the effect sizes were very small. The main finding from this study is thus that parasuicide patients in different countries tend to indicate that similar types of intentions are involved in their acts of parasuicide, and that the intentions do not vary greatly with gender or age. The hypothesis that rates of suicide and parasuicide vary between regions with the frequency with which suicidal intention is indicated by the patients was also tested, but was supported only for women and in relation to national suicide rates. The findings from this study are likely to be generalizable to other settings and have implications for clinical practice.

Repetition of attempted suicide among teenagers in Europe: frequency, timing and risk factors

Background. Adolescents in many countries show high rates of suicide attempts and repetitions of attempts as a common feature. Attempted suicide is the best predictor of future suicide. Repetition of attempts further increases the risk of suicide. The present study sought to identify patterns and risk factors for repetition of attempts in older teenagers. Methods. Data were collected by uniform procedures in a longitudinal follow-up study in seven European centres participating in the WHO/EURO Multicentre Study on Suicidal Behaviour. Information on attempted suicide in the 15–19-year age group during the period 1989–1995 was analysed. Results. A total of 1,720 attempts by 1,264 individuals over a mean follow-up period of 204 weeks (SD 108.9) were recorded. When life-table analysis was performed, 24 % of the individuals who had previously attempted suicide made another attempt within one year after the index attempt, compared with 6.8 % of the “first-evers”, with no major gender difference. Cox regression analysis revealed that previous attempted suicide (OR 3.3, 95 % CI 2.4–4.4) and use of “hard” methods (OR 1.5, 95 % CI 1.1–2.1) were both significantly associated with repetition of attempted suicide. Stepwise Cox regression analysis showed that a history of previous attempted suicide was the most important independent predictor of repetition (OR 3.2, 95 % CI 2.4–4.4). Conclusion. For young suicide attempters, follow-up and adequate aftercare are very important if repetition and risk of suicide are to be reduced. This applies particularly to those who have already made more than one attempt.

Psychological Autopsy Studies as Diagnostic Tools: Are They Methodologically Flawed?

One of the most established “truths” in suicidology is that almost all (90% or more) of those who kill themselves suffer from one or more mental disorders, and a causal link between the two is implied. Psychological autopsy (PA) studies constitute one main evidence base for this conclusion. However, there has been little reflection on the reliability and validity of this method. For example, psychiatric diagnoses are assigned to people who have died by suicide by interviewing a few of the relatives and/or friends, often many years after the suicide. In this article, we scrutinize PA studies with particular focus on the diagnostic process and demonstrate that they cannot constitute a valid evidence base for a strong relationship between mental disorders and suicide. We show that most questions asked to assign a diagnosis are impossible to answer reliably by proxies, and thus, one cannot validly make conclusions. Thus, as a diagnostic tool psychological autopsies should now be abandoned. Instead, we recommend qualitative approaches focusing on the understanding of suicide beyond mental disorders, where narratives from a relatively high number of informants around each suicide are systematically analyzed in terms of the informants’ relationships with the deceased.

Self-Reported Suicidal Behavior and Attitudes Toward Suicide and Suicide Prevention Among Psychology Students in Ghana, Uganda, and Norway

Self-reported suicidal behavior and attitudes toward suicide in psychology students are reported and compared in Ghana, Uganda, and Norway. Small differences only were found in own suicidal behavior. However, experience of suicidal behavior in the surroundings was more common in Uganda than in Ghana and Norway. Although differences were found between the three countries in attitudes toward suicide, which emphasizes the need for culture-sensitive research and prevention, many of the differences were not as big as expected. The most pronounced difference was that the Norwegian students were more reluctant to take a stand on these questions compared to their African counterparts. Some differences were also found between the two African countries. The implications of the results for suicide prevention in Africa are discussed.

Problem solving ability and repetition of deliberate self-harm: a multicentre study.

BACKGROUND While recent studies have found problem-solving impairments in individuals who engage in deliberate self-harm (DSH), few studies have examined repeaters and non-repeaters separately. The aim of the present study was to investigate whether specific types of problem-solving are associated with repeated DSH. METHOD As part of the WHO/EURO Multicentre Study on Suicidal Behaviour, 836 medically treated DSH patients (59% repeaters) from 12 European regions were interviewed using the European Parasuicide Study Interview Schedule (EPSIS II) approximately 1 year after their index episode. The Utrecht Coping List (UCL) assessed habitual responses to problems. RESULTS Factor analysis identified five dimensions--Active Handling, Passive-Avoidance, Problem Sharing, Palliative Reactions and Negative Expression. Passive-Avoidance--characterized by a pre-occupation with problems, feeling unable to do anything, worrying about the past and taking a gloomy view of the situation, a greater likelihood of giving in so as to avoid difficult situations, the tendency to resign oneself to the situation, and to try to avoid problems--was the problem-solving dimension most strongly associated with repetition, although this association was attenuated by self-esteem. CONCLUSIONS The outcomes of the study indicate that treatments for DSH patients with repeated episodes should include problem-solving interventions. The observed passivity and avoidance of problems (coupled with low self-esteem) associated with repetition suggests that intensive therapeutic input and follow-up are required for those with repeated DSH.

Attempted suicide and major public holidays in Europe: findings from the WHO/EURO Multicentre Study on Parasuicide

Objective: The aim of the study was to examine the relationship between suicide attempts and major public holidays in Europe.

Deliberate self-harm as seen in Kampala, Uganda - a case-control study.

Abstract.Objectives:A study to investigate deliberate self-harm (DSH) in an African context was undertaken in Uganda.Methods:A case-control study in which 100 cases of DSH and 300 controls matched on age and sex were recruited from three general hospitals in Kampala and subjected to a structured interview using a modified version of the European Parasuicide Study Interview Schedule I.Results:Among the cases, 63% were males, with a male to female ratio of 1.7:1 and a peak age range of 20–24 years. Higher educational attainment, higher socio-economic class and poor housing were significantly associated with DSH. District of current residence, district of birth, religion, ethnicity, marital status, number of children, current living arrangement, area of usual residence, employment status of respondent and partner were not significantly associated with DSH. Pesticides and medications, mainly antimalarials and diazepam, were the main methods of DSH used. The most commonly reported psychiatric disorders were adjustment disorder, acute stress reactions and depression.Conclusion:DSH in Uganda appears to predominantly afflict the young. Disturbed interpersonal relationships, poverty and loneliness were important factors in the immediate precipitation of this behaviour. The fact that pesticide poisoning is still the predominantly used method in DSH in this area calls for a review of the legislation that controls the sale and availability of these agricultural chemicals.

Cultural Context Is Crucial in Suicide Research and Prevention

According to Geertz (1973), “. . . there is no such thing as a human nature independent of culture . . . We are . . . incomplete or unfinished animals who complete or finish ourselves through culture . . .” (p. 49). And, in the words of Markus and Hamedani (2007), “. . . biological beings become human beings through their engagement with the meanings and practices of their social world . . .” (p. 32). Thus, the sociocultural context is crucial to peoples’ lives, which inevitably means that it also plays a crucial role in suicide. If we want to understand suicidal behavior and suicidal people, it is absolutely essential to take the cultural context into consideration in all kinds of suicidological research (e.g., Hjelmeland, 2010; Hjelmeland & Knizek, 2010; Hjelmeland & Knizek, in press). This should be selfevident. However, it turns out not to be, and in an endeavor to include a cultural perspective in suicidological research we face a number of challenges – conceptual, theoretical, methodological, ethical, and political challenges (Hjelmeland, 2010). One of the most important challenges, and the one to be discussed here, might be the current “biologification” of suicidology. Among other sciences, psychiatry is one of the most prominent premise providers for suicidology; and there is no doubt that psychiatry, as well as behavioral sciences, have recently developed in a more biological direction (Brinkmann, 2009). Thus, studies on biological factors (e.g., genes, endophenotypes, neurotransmitters) are presently in demand (e.g., Mann et al., 2006), researchers are now describing the “suicidal brain” (e.g., Desmyter et al., 2011), and various kinds of brain-imaging techniques are developing fast and maintained to be important also in suicidology. For example, Mann (2005) stated that “The clinician needs to know which depressed patient is at risk for suicide, and one promising direction is to begin using brain imaging to measure the predisposition to suicidal behavior . . .” (p. 102). With this, we face some ethical challenges. For instance, when and how is the information produced in such studies going to be used? If you are told that you have a biological predisposition to suicide (or not), this information will inevitably have consequences for both you and your family and friends (Hjelmeland & Knizek, in press). Moreover, such studies have their limitations. For instance, Restak (2006) pointed out that correlations found in brainimaging research frequently – and inappropriately – are interpreted in terms of cause and effect relationships. Furthermore, with the new brain-imaging techniques, psychiatry, and with it suicidology, may be heading toward (or back to?) a very mechanistic view of human beings. A potential consequence of finding biological markers for suicidal behavior is that this makes it rather easy to think of medication as the best/cheapest/easiest possible treatment available. It may be considered easier to treat what is often referred to as “a chemical imbalance in the brain” with chemicals instead of spending a lot of resources on unveiling the reason(s) for this “imbalance,” which very well may be found in the person’s sociocultural environment, so that the patient should therefore rather be treated with alternative therapies. Take the current debate about whether the increased use/sales of antidepressants contributed to, or even caused, a reduction in suicide rates (e.g., Isacsson, Rich, Jureidini, & Raven, 2010). Even though, according to Jureidini and Raven, the evidence base for such a relationship has proven methodologically weak, Isacsson and Rich maintain that “treatment with antidepressants prevents suicide” (Isacsson et al., 2010, p. 429). Governments, for example, perhaps welcome such simple solutions to complex problems, so that researchers have a duty not to contribute to untenable simplification. In fact, the relationship between use of antidepressants and risk of suicidality has proved to be rather complex. A meta-analysis of 372 double-blind, randomized, placebo-controlled trials demonstrated that this risk was strongly dependent on age: Only among older adults (> 64 years) was the risk of suicidality found to be reduced with use of antidepressants, whereas there was no effect for the age group 25–64 – and even an increased risk for those under 25 years (Stone et al., 2009). Because of the high cost of brain-imaging equipment, it

A comparative study of young and adult deliberate self-harm patients.

Research has shown that the prevalence of deliberate self-harm (DSH) is higher in adolescents than in adults, but little is known about other differences. In this study we compare adolescent and adult DSH-patients regarding factors contributing to the suicidal act. In two regions in Norway, 98 persons under 20 years of age and 83 older persons were interviewed following an act of DSH. They were compared regarding intentions involved in the DSH, precipitating circumstances, level of suicidal intent, medical seriousness of the act, depression, hopelessness, and self-esteem. Few differences were found. The adults more often wanted to escape from unbearable thoughts or situations, or to receive care and attention. Adults also reported a slightly higher level of medical seriousness of the DSH act, more psychiatric problems, and substance abuse. The similarities between young and adult DSH-patients are striking. The differences found are most likely related to factors of age itself, such as cognitive immaturity, impulsivity, and lack of experience in enduring problems.